Transanal Small Bowel Eviceration due to Traumatic Rectal Perforation

Transanal small bowel evisceration by rectal perforation is a very rare presentation. It occurs spontaneously or in association with trauma. We experienced a 20-year-old female patient who had transanal evisceration of the small bowel due to blunt trauma. Operative findings showed traumatic rectal perforation and gangrenous change of the eviscerated small bowel due to tearing of the small bowel mesentery. Segmental resection of gangrenous small bowel with immediate anastomosis and Hartmann's procedure of rectal perforation were performed. After 9 months, reduction of sigmoid colostomy and colorectal anastomosis were performed. We report this rare case with a review of the literature.

IMA-origin Lymph Node Metastasis in Left Colon Cancer

PURPOSE: Although an extended colon resection with high ligation of the inferior mesenteric artery (IMA) generally has been recommended as curative surgery for advanced left colon cancer (LCC), it shows little or no survival advantage over segmental resection with low ligation of IMA. The present study is to determine the risk factors associated with IMA-origin lymph-node (LN) metastasis and to clarify the implication of IMA-origin LN metastasis. METHODS: We examined the clinicopathological results of 200 cases of LCC. LN dissection was performed as follows: D2 en-bloc resection of the primary tumor, IMA-origin LN dissection, and paraaortic LN dissection. RESULTS: The incidence of IMA-origin LN metastasis of LCC was 4.5% (9 cases), and all cases involved sigmoid colon cancer. The independent risk factors of IMA-origin LN metastasis were four or more regional LN metastases (hazard ratio: 16.51, 95% confidence interval: 1.60~164.12) and a preoperative CEA level of greater than 6 ng/ml of (hazards ratio: 6.63, 95% confidence interval: 1.06~41.32). The incidence of IMA-origin LN metastasis among stage IIIC patients was 26.7%. Five of the 9 (55.6%) cases of IMA-origin LN metastasis had a concomitant paraaortic LN metastasis. CONCLUSIONS: The incidence of IMA-origin LN metastasis among patients with LCC was low; however, IMA-origin LN metastasis should be considered as a systemic metastasis.

Effect of Prolonged Thrombus Exposure on the Development of Secondary Venous Wall Changes in a Rat Venous Thrombosis Model

PURPOSE: There is growing evidence that thrombosis and inflammation are closely interrelated and that the inflammatory response may play a role in the development of the syndrome of post-thrombotic, chronic venous insufficiency. A thrombus contains biologically active factors that stimulate cellular and structural alterations and lead to post-thrombotic venous abnormalities. Prolonged exposure to thrombus may result in the development of more severe pathologic conditions. To assess the effect of prolonged thrombus exposure on the development of secondary venous wall changes, the level of D-dimer test and the microscopic findings of thrombosed vein were analyzed in a rat venous thrombosis model. METHOD: The left iliac vein of male Sprague-Dawley rats weighing of 250 to 300 gm were thrombosed by means of either proximal ligation or temporary 24-hour occlusion with a microvascular clamp. The rats were divided into three groups: control group (n=10), thrombosis model by proximal ligation of the iliac vein only; group A (n=10), thrombosis model by proximal ligation of the iliac vein with treatment of low molecular weight heparin (LMWH; Clexane(r) 0.5 mg/kg, s.c.b.i.d); and group B (n=10), thrombosis model by temporary 24-hours clamp of the iliac vein without treatment of LMWH. The vein located 2 cm below from the initial ligation was harvested at time intervals of 7 and 14 days after ligation or clamp. Thrombi were identified by gross findings and indirectly quantitated with D-dimer test. RESULT: The levels of D-dimer test on days 7 and 14 after ligation or occlusion were significantly higher in the control group than in groups A and B (P<0.05). However, gross findings of intraluminal thrombosis were not present only in group B. These findings suggest that injection of LMWH did not prevent the development of thrombi around the ligation area. The neutrophilic infiltration of the perivascular area was evaluated microscopically (Hematoxylin-Eosin stain, x100). Severe perivascular neutrophilic infiltration was found in the control group and group A, whereas in group B neutrophilic infiltration was decreased to a mild or moderate degree. The vein wall thickness was evaluated by counting cells on representative sections through the mid vein area and by direct measuring of the vein wall usinga scale bar. The rat vein walls on days 7 and 14 were significantly thicker in the control group and group A than in group B (P<0.05). CONCLUSION: These results suggest that prolonged exposure of thrombus plays a major role in the development of secondary venous wall changes. However, the injection of LMWH did not prevent the development of secondary venous wall changes during the prolonged exposure of thrombus.

The Effect of Tissue Plasminogen Activator on Intimal Hyperplasia after Balloon Injury to Rat Aorta

PURPOSE: Thrombus formation enhances both neointima formation and clinical restenosis after vascular injury or angioplasty. Thrombotic occlusions and intimal hyperplasia limit the success of vascular reconstructive procedures. Thrombolysis is expected to improve the outcome for both restenosis and acute arterial occlusion after injury. Tissue-type plasminogen activator (tPA) is commonly used clinically, and it is thought to play a critical role in vascular remodeling by mediating intravascular clot lysis and modulating cell migration within the vessel wall. However, there is controversy about the late effects of tPA on the vascular lumen either for preventing or enhancing intima hyperplasia in vivo. Thus, this study was done to evaluate the impact of a clinical infusion of tPA on the neointima formation after a balloon injury. METHOD: Forty male Sprague- Dawley rats weighting of 250~300 gm each were underwent aortic intimal denuation with a 2F balloon catheter. The rats were divided into two groups: the control group (n=20: normal saline infusion), and the*ean IMAR on the 21st day was 1.14+/-0.16 in the control group and 1.10+/-0.11 in the experiment group. The mean IMAR was lower in the experiment group, but the result was not statistically significant. In comparison to the gelatinolytic activity of MMP-9 and, activated MMP-2, there was no significant difference between the two groups. CONCLUSION: These results suggest that the effect of tPA on intimal hyperplasia after balloon injury to rat aorta showed minimal significance.